N328 Exam 2 Practice Questions | Answered with Complete Solutions

N328 Exam 2 Practice Questions | Answered with Complete Solutions A nurse is obtaining an infant's vital signs. The HR is 180 bpm, and the temperature is 40C (104F). The father asks the nurse, "Why is my baby's heart ...

N328 Exam 2 Practice Questions | Answered with Complete Solutions A nurse is obtaining an infant's vital signs. The HR is 180 bpm, and the temperature is 40C (104F). The father asks the nurse, "Why is my baby's heart beating so fast?" Which of the following is an appropriate response by the nurse? A. "This is within the expected range for your baby." B. "The fever is causing an increase in your baby's heart rate." C. "As your baby begins to fall asleep, the heart rate will decrease." D. "Your baby's heart is beating fast in an attempt to cool down the body." Rationale: The expected range for the temperature of an infant from birth to 1 year is 36.5° C (97.7° F) to 37.2° C (98.9° F). This infant has a fever. The infant's heart rate will increase as a result of the fever. The expected range for heart rate in an infant 3 months to 2 years old is 80-150/min while awake and 70-120/min while asleep. If the infant is active or has a fever, the heart rate may be as high as 220/min. A nurse is caring for a child who is diagnosed with otitis media. Which of the following assessment findings should the nurse expect? A. Tugging on the affected ear lobe B. Clear drainage from the affected ear C. Pain when manipulating the affected ear lobe D. Erythema and edema of the affected ear Rationale: Otitis media is a middle ear infection. Expected findings include fever, purulent drainage (only if the tympanic membrane is ruptured), and pain, demonstrated by the child tugging at the ear. Pain when manipulating the ear lobe is the classic sign of otitis externa, swimmer's ear. Swimmer's ear is also associated with erythema and edema of the affected ear. Clear drainage from the ear is more commonly associated with CSF drainage. A nurse is preparing to begin chest compressions for an infant. The nurse should perform compressions using which of the following techniques? A. Deliver compressions at 1/3 to 1/2 the depth of the chest. B. Deliver compressions with the heel of one hand only. C. Deliver compressions just above the nipple line. D. Deliver compressions at a depth of 1 1/2 to 2 inches. A nurse is monitoring a child who has just had a tonsillectomy for signs of hemorrhage. Which of the following findings is a sign of this postoperative complication? A. Mouth breathing B. Frequent swallowing C. Reports of thirst D. Reports of pain A nurse is caring for a child who is experiencing an acute asthma attack. Which of the following medications should the nurse administer first? A. Fluticasone (Flovent) B. Budesonide (Pulmicort) C. Montelukast (Singulair) D. Albuterol (Proventil) A nurse in a clinic sees a client who has an acute asthma exacerbation. Which of the following medications should reduce the symptoms? A. Cromolyn (Intal) via metered-dose inhaler B. Oral montelukast (Singular) C. Budesonide (Pulmicort) via dry-powder inhaler D. Albuterol (Proventil) via jet nebulizer A nurse is assessing a client who has asthma and signs of central cyanosis. Which of the following is a reliable indicator of cyanosis? A. Oral mucosa B. Finger tips C. Ear lobes D. Eye lids Rationale: The nurse should assess the oral mucosa as an indicator of cyanosis because changes can be seen easily in areas with less pigmentation. A nurse is caring for a child with a suspected diagnosis of cystic fibrosis. Which of the following diagnostic tests will the nurse prepare the child for to confirm the diagnosis? A. Sweat chloride test B. A sputum culture C. A stool fat content analysis D. Pulmonary function test Rationale: Clients with cystic fibrosis have an increase of sodium and chloride in both saliva and sweat. Therefore, a sweat chloride test is a definitive diagnostic test to determine the diagnosis of cystic fibrosis. A nurse is caring for a child who has cystic fibrosis (CF) and is being discharged after initial diagnosis and treatment. The nurse should recognize that the parent understands the child's nutritional needs when she states which of the following? A. "I will make certain that pancreatic enzymes are taken with all of my child's snacks and meals." B. "I will restrict the amount of salt in my child's food." C. "I will limit my child's fluid intake." D. "I will prepare low-fat meals for my child." Rationale: CF interferes with the availability of pancreatic enzymes necessary for normal digestion and absorption of nutrients. Therefore, pancreatic enzymes must be taken with all meals and snacks. A nurse is preparing a 4 year old client for discharge following a bilateral myringotomy with tympanostomy tube placement. The mother asks what to do if the tubes fall out. The nurse should give the parent which of the following instructions? A. Gently reinsert the tubes. B. Take the child to the emergency department. C. Call the health care clinic to report that the tubes have fallen out. D. Reassure the mother that the tubes will not fall out. A nurse is teaching the mother of a 5 year old child with CF about pancreatic enzymes. The nurse understands that further teaching is needed when the mother states which of the following? A. "I will give my son the enzymes between meals." B. "The enzymes probably won't cause a lot of side effects." C. "The enzymes help him digest fat." D. "I will put the enzyme crystals in his applesauce." A nurse is reinforcing discharge teaching with the parents of a preterm infant who has a prescription for home oxygen and pulse oximetry monitoring. Which of the following statements by the parents indicates a need for further teaching? A. "We will rotate the probe of the pulse oximeter every 24 hours." B. "The probe of the pulse oximeter can be applied to a finger or a toe." C. "The pulse oximeter may not be accurate during times of excessive movement." D. "We will notify the doctor if the pulse oximeter consistently reads 100%." Rationale: Pulse oximeters are a noninvasive method of monitoring oxygen saturation (SaO2) of the blood. It is obtained by the application of a probe around the hand, foot, finger, toes, or earlobe, which is then connected to a machine that provides continuous oxygen saturation levels. The probe should be rotated every 3 to 4 hr to prevent pressure necrosis from occurring. Excessive movement, as well as heat and light, can interfere with the results. Due to the risk of oxygen toxicity, which is a particular concern with preterm infants, the parents should be instructed to notify the provider for consistent SaO2 readings over 95%. This may be an indication the infant is receiving too much oxygen and the amount should be decreased. A nurse is caring for a toddler admitted with laryngotracheobronchitis who is placed in a cool mist tent. As a result of this treatment, the nurse expects to observe... A. barking cough. B. improved hydration. C. decreased stridor. D. decrease in fever. Rationale: Laryngotracheobronchitis, or croup, is a condition of breathing difficulty common in infants caused by infection of the upper airway (larynx, trachea, and bronchus) and characterized by a barking cough. Edema and obstruction in the upper airways cause the characteristic cough and stridor (noisy breathing). The child's breathing becomes more difficult and requires increasing physical effort. The direct purpose of a cool mist tent is to humidify the inspired air, which will decrease the respiratory effort. A nurse is caring for a child who has a tracheostomy. After suctioning the tracheostomy, the nurse determines that the procedure was effective with which of the following assessment findings? A. Increased respiratory rate B. Stable oxygen saturation C. Clear breath sounds D. Brisk capillary refill A nurse is admitting a 9 year old child who has acute rheumatic fever. When obtaining the client's history, it is appropriate for the nurse to ask the parent which of the following questions? A. "Has your son had a sore throat recently?" B. "Was your son born with this cardiac defect?" C. "Has your child had any injuries recently?" D. "Are you aware that your son will have to be in isolation?" Rationale: Rheumatic fever typically develops 2 to 6 weeks after an untreated or ineffectively treated streptococcal infection of the respiratory tract. It is appropriate to determine whether or not the child previously has a sore throat. A nurse is planning care for a child with suspected epiglottitis. Which of the following is an appropriate action for the nurse to take? A. Obtain a throat culture. B. Place client in an upright position. C. Transfer for a throat x-ray. D. Visualize the epiglottis with a tongue depressor. Rationale: Placing the child in an upright position will assist in maintaining a patent airway and is an appropriate action for the nurse to take. Obtaining a throat culture on a child and attempting to visualize the throat with a tongue depressor with suspected epiglottitis could precipitate obstruction of the airway and should be avoided. To relieve thirst following a tonsillectomy, a nurse should offer a child which of the following? A. Orange ice pop B. Orange juice C. Ice cream D. Cranberry juice Rationale: Cold, clear liquids are well-tolerated following a tonsillectomy. Liquids that are brown or red should be avoided in order to tell the difference between the liquid and fresh or old blood. Acidic fluids should be avoided as they can be irritating to the throat. Dairy products should be avoided as they increase the viscosity of the mucus, causing the child to frequently clear her throat. This can lead to bleeding. A nurse is caring for a school-age child who has mild persistent asthma. Which of the following is an expected finding? (Select all that apply.) A. Symptoms are continuous throughout the day. B. Daytime symptoms occur more than twice a week. C. Nighttime symptoms occur approximately twice a month. D. Minor limitations occur with normal activity. E. Peak expiratory flow (PEF) is greater than or equal to 80% of the predicted value. A nurse is caring for a preschool age child who has epiglottitis with a barking cough. Which of the following is an appropriate nursing action? A. Encourage coughing. B. Attempt to obtain a throat culture. C. Visualize the back of the throat. D. Apply oxygen. Rationale: Applying high-flow oxygen on the client and keeping the client calm is an appropriate action by the nurse to improve oxygenation. The other three actions may precipitate a complete obstruction. A nurse is providing teaching to the parent of a child diagnosed with acute group A beta-hemolytic streptococci. Which of the following should the nurse include in the teaching? A. Avoid the use of warm compresses around the head or neck. B. Intramuscular injections will be required monthly. C. Replace the child's toothbrush after 24 hr on antibiotics. D. Keep the child home from school for at least 1 week. Rationale: This is done to prevent the spread of infection or re-infection. A nurse is teaching an assistive personnel to count respiration rate on a newborn. Which of the following statements indicates understanding of why the respiratory rate should be counted for a complete minute? A. "Newborns are abdominal breathers." B. "Newborns do not expand their lungs fully with each respiration." C. "Activity will increase the respiration rate." D. "The rate and rhythm are irregular in newborns." Rationale: Abdominal breathing, varied labor of breathing, and activity increasing the respiratory rate have no impact on obtaining a respiratory rate. A nurse is caring for a child diagnosed with pertussis. The nurse should respond with which of the following when asked by the parent what the common name for this disorder is? A. Chickenpox B. Whooping cough C. Mumps D. Fifth disease A nurse in a PACU is admitting a client who is postoperative following a tonsillectomy. Which of the following actions should the nurse take to prevent aspiration? A. Place a bedside humidifier at the head of the client's bed. B. Suction the nasopharynx as needed. C. Withhold fluids until the client demonstrates a gag reflex. D. Perform chest physiotherapy (CPT). A 4 year old child who has croup is admitted to the hospital and wets the bed overnight. When the parent comes to visit the next day, the nurse explains the situation and the parent says, "My child never wets the bed at home. I am so embarrassed." Which of the following is an appropriate response by the nurse? A. "It is normal for hospitalized children to regress. The toileting skills will return when your child is feeling better." B. "I know this can really be embarrassing. I have kids myself, so I understand, and it doesn't bother me." C. "Your child did not seem upset, so I wouldn't worry about it if I were you." D. "I will discuss your child's loss of bladder control with the physician, as this may require further investigation." A nurse is caring for a 6 month old who is postoperative following a myringotomy. Which of the following is an appropriate method to determine the infant's pain level? A. FLACC pain scale B. OUCHER pain scale C. Faces pain scale D. Visual analog pain scale A nurse is teaching the parents of a child who has a streptococcal infection about preventing disease transmission. Which of the following instructions should the nurse include? A. "I'll continue to encourage him to drink lots of fluids." B. "I'll take his temperature every 4 hr." C. "I'll give him Tylenol for the pain." D. "I'll discard his toothbrush and buy another." The parents of a 7 year old child bring her to the emergency department. They tell the nurse that she awoke with a tympanic temperature of 39.2C (102.2F), an extremely sore throat, drooling, and difficulty swallowing. Which of the following actions is the nurse's priority? A. Insert an IV catheter. B. Obtain culture specimens. C. Administer an antipyretic. D. Prepare for intubation. Rationale: The client's signs and symptoms suggest epiglottitis, which is a respiratory emergency. Airway obstruction is imminent, and that is the greatest risk to the client's safety at this time, so the nurse must prepare for intubation to maintain airway patency. A nurse is caring for a hospitalized 4 year old child who is on airborne precautions. Which of the following activities is appropriate for the nurse to implement for this child? A. Putting a puzzle together B. Watching a video game in the playroom C. Pulling a wagon with toys in the hallway D. Constructing a model airplane A nurse is caring for a 12 month old toddler who is hospitalized and confined to a room with contact precautions in place. Which of the following toys should the nurse suggest in order to meet the developmental needs of the client? A. Large building blocks B. Hanging crib toys C. Modeling clay D. Crayons and a coloring book A nurse is monitoring an infant who is 3 months old and has sneezing, coughing, nasal congestion, intermittent fever, and apneic spells. These findings are associated with which of the following diagnoses? A. Influenza B. Bronchiolitis C. Croup D. Epiglottitis A nurse is caring for a 7 year old client who has a diagnosis of upper respiratory infection and a history of type 1 diabetes mellitus. Which of the following statements by the mother indicates a need for further instruction? A. "I will encourage drinking a half a cup of water or sugar-free fluids every 30 minutes." B. "I will report a change in breathing or any signs of confusion." C. "I will notify the doctor if the temperature is not controlled with acetaminophen." D. "I will continue to check his blood sugar two times a day." A nurse in the emergency department is caring for a client who has epiglottitis. The child is crying, and the parents are concerned that their child has not had anything to eat or drink for several hours. They also have expressed a fear that their other children may contract the illness. Which of the following responses should the nurse give? A. "The influenza vaccine can protect your other children from epiglottitis." B. "Did you bring an item that will help comfort your child?" C. "The nurse practitioner will be in shortly to obtain a throat culture." D. "Your child can drink, but cannot have anything solid." A nurse is assessing a child after a tonsillectomy. Which of the following is a clinical manifestation of a hemorrhage? A. Increased pain B. Poor fluid intake C. Drooling D. Continuous swallowing A nurse is caring for a child with a suspected diagnosis of bacterial meningitis. Which of the following is the priority action by the nurse? A. Administer antibiotics when available. B. Reduce environmental stimuli. C. Document intake and output. D. Maintain seizure precautions. Rationale: The priority nursing action is to administer antibiotics when available. Bacterial meningitis is an acute inflammation of the meninges and the CNS, and antibiotic therapy has a marked effect on the course and prognosis of the illness. A parent is concerned that her 5 year old child may be exhibiting regression behaviors. The nurse should know the behavior that indicates regression is... A. cuddling a threadbare blanket at bedtime. B. crying when mother leaves. C. eating only food from home. D. bedwetting several times a day. A nurse is caring for a child who has just received a ventriculoperitoneal (VP) shunt. Which of the following should the nurse know is the appropriate position for this client? A. Dorsal recumbent B. On the operative side C. Prone D. Low Fowler's Rationale: A VP shunt is surgery performed to relieve intracranial pressure caused by hydrocephalus (enlargement of the ventricles of the brain with cerebrospinal fluid). Shunting is necessary to drain the excess fluid and relieve the pressure in the brain. Elevating the head of the bed 30 degrees in the immediate postoperative period helps to decrease swelling and pressure in the brain. A nurse is assessing an 11 month old infant. Which of the following clinical manifestations is suggestive of a central nervous system infection? A. Oliguria B. Bulging fontanel C. Negative Brudzinski sign D. Jaundice Rationale: A central nervous system infection causes increased intracranial pressure. Therefore, bulging fontanel is a clinical manifestation of a central nervous system infection. A positive Brudzinski sign is a clinical manifestation of a central nervous system infection. Which of the following is an example of a neural tube defect? A. Cerebral palsy B. Hydrocephalus C. Muscular dystrophy D. Spina bifida A nurse is assessing an infant who has possible cerebral palsy. Which of the following manifestations of cerebral palsy should the nurse expect to find? A. Tracks an object in surroundings with eyes. B. Sits with pillow props at eight months. C. Smiles when mother appears at three months. D. Uses pincher grasp to pick up a toy. A nurse is caring for a child that is having a tonic-clonic seizure and vomiting. Which of the following is the priority nursing action? A. Place a pillow under the child's head. B. Position the child side-lying. C. Loosen restrictive clothing. D. Clear the area of hazards. Rationale: To prevent aspiration due to vomiting, the nurse should place the child in a side-lying position. A nurse on a pediatric unit is caring for a client who has a brain tumor. To ensure the client's safety, which of the following actions should the nurse take? A. Do not allow the child to ambulate in his room alone. B. Limit contact with other pediatric clients. C. Initiate seizure precautions for the child. D. Have the child use a wheelchair for all out-of-bed activities. A nurse is orienting a newly licensed nurse in the care of an infant diagnosed with spina bifida (myelomeningocele). Which of the following actions by the new nurse indicates teaching has been effective? A. Performing range of motion on the hips B. Maintaining of a dry dressing over the myelomeningocele sac C. Taking an axillary temperature on the newborn D. Placing infant in a side-lying position Rationale: Infants should be place prone with myelomeningocele to avoid accidental rupture of the sac. Drying of the myelomeningocele should be prevented with the application of sterile, moist, nonadhesive dressings until surgical repair can be performed. A nurse is caring for a child who is having a seizure. Which of the following is an appropriate action by the nurse? (Select all that apply.) A. Assess the client's airway patency. B. Place a tongue depressor in the client's mouth. C. Place the bed in a low position. D. Place the client in prone position. E. Restrain the client. A parent tells a nurse that his 2 month old infant was well until 2 weeks ago, when the infant began spitting up after eating. "Now the vomit practically shoots across the room. After my baby vomits, she cries and acts very hungry." The appropriate response by the nurse is which of the following? A. "You should bring your infant in to the clinic today to be seen." B. "You need to burp your baby more frequently during feedings." C. "You should give your infant an oral rehydrating solution." D. "You might want to try switching to a different formula." Rationale: The symptoms of worsening projectile vomiting, which began at about 6 weeks of age, and the child acting hungry afterward, are characteristic of pyloric stenosis. The baby needs to be examined in the clinic by the provider as soon as possible. A nurse is providing teaching to the parent of an infant who has gastroesophageal reflux. Which of the following statements by the parent indicates an understanding of the teaching? A. "I will keep my baby in an upright position after feedings." B. "My baby's formula can be thickened with oatmeal." C. "I will have to feed my baby formula rather than breastmilk." D. "I should position my baby side-lying during sleep." A nurse is caring for a male infant admitted with a palpable mass in the upper right quadrant, and passage of stools mixed with blood and mucus. Which of the following diagnoses are these findings associated with? A. Tracheoesophageal fistula B. Inguinal hernia C. Hypertrophic pyloric stenosis D. Intussusception A nurse is caring for a 6-week-old infant client who was admitted to the pediatric unit for evaluation of a suspected pyloric stenosis. Which of the following nurse assessments is consistent with this diagnosis? A. Distended abdomen B. Effortless regurgitation